More on Sensory Integration Disorder

Following a previous blog post on Sensory Integration Disorder, and our discussion regarding the evidence for this diagnosis, we have become aware of more information that is relevant, and which makes a significant contribution to this discussion.

For those interested, here is the link to the Policy Statement on Sensory Integration Disorder from the American Academy of Paediatricians from May 2012.  

http://pediatrics.aappublications.org/content/early/2012/05/23/peds.2012-0876.full.pdf

We hope our readers find this further information helpful in their clinical work.

Linda and Frank

Dyslexic or not dyslexic?

 Happy New Year to everyone, we trust that you all had a relaxing break.

As we move into 2013, it is a good time to reflect on the current state of the art of paediatric neuropsychology and assessment.

As a neuropsychologist doing some work in the community, an ongoing area of confusion and discussion that has been relevant for this private work is the accurate and valid assessment of learning and literacy disorders in children. This can often be confusing, as speaking to different experienced clinicians or researchers about this topic can yield different answers regarding the diagnostic criteria for a specific literacy disorder. Many times, the responses on exactly how to diagnosis such a developmental disorder are vague and sometimes even uncertain.

As I understand it, part of the reason for this ambiguity is that setting a diagnostic threshold for a literacy disorder, for example dyslexia, can be somewhat arbitrary, given that reading skill is a continuum, leading to some confusion in categorising ‘dyslexic’ from ‘not dyslexic’. The confusion widens when we discuss whether this diagnostic threshold should be relative to age or IQ expectations.

Traditional definitions have required that the reading deficits are significantly below the IQ level of the child. This the raises fundamental issue that IQ is correlated with measures of reading and spelling, in a way confounding the assessment and diagnosis. There is also the issue that there are many children who will not be diagnosed using this definition (even though their reading skill is well below age expectation and is interfering with their functioning) as their IQ is also at a low level. An interesting point made by Pennington (2009) is that if this was to remain our diagnostic definition, we would ironically be systematically excluding those that are arguably the most severe cases (those with low reading skill and low IQ).

Recent research has looked into the differences between IQ discrepancies and age discrepancies in diagnosing dyslexia. At this stage, it seems that maintaining a distinction between these two methods of diagnosis is hard to justify, given that there is no external validity for the distinction, and also that treatments appear to be just as efficacious for those with and without IQ discrepancies. Therefore, the current consensus is that children should be identified and treated with a specific reading disorder, or dyslexia, if they meet either definition.

The ongoing problem with both definitions remains that any chosen diagnostic threshold is arbitrary. Pennington (2009) argues that an age based discrepancy requires an age based standardisation score of 80 or lower (a 1.3 standard deviation cut-off). For an IQ based cut-off, the predicted reading score should be used, along with a chosen level of discrepancy from that predicted score. Pennington suggests that a discrepancy of 20 is used (again, a 1.3 standard deviation cut-off is employed). Therefore, a score which is 20 standardised points lower than the predicted reading score can be considered to be diagnostic.

Despite the diagnostic criteria surrounding literacy disorders (as well as other related language and numeracy disorders) becoming clearer with ongoing research, it still remains a grey area, with clinical judgement an important aspect of such an assessment. Importantly, this discussion is not to mention the evidence-based intervention for these literacy difficulties... a can of worms for another time.

We would be very interested to hear about views on this topic, and about your experiences in these types of assessment.

Wishing you all lots of success and good wishes for 2013.

Frank and Linda

References

Pennington, B.F. (2009). Diagnosing learning disorders: A neuropsychological framework (Second Edition). New York, Guilford Press.

Upcoming conferences

Abstracts close on Feb 15 for the INS meeting in Amsterdam (July 10-13 2013). 

The issue of fish oil supplements

Time to blog a few more thoughts about the world of paediatric neuropsychology.  

One issue that is always topical is dietary supplements and fish oil in particular as a means of improving cognition or behaviour.  As is the case for adults, dietary supplements for children and readily available, some parents are strong advocates, others more neutral and yet others active avoiders. My own personal view has been that if a child’s diet is adequate then there is nothing much to be gained, but I have never really looked at the literature and it is something that parents ask about from time to time. A basic survey of the literature initially had me feeling like I might be missing something with my neutral position on this issue. Titles referring to enhanced sporting performance with dietary supplements, gains in IQ with prenatal fish oil supplements and a proposal to roll out fish oil to children in remote indigenous communities (Sinn et al., 2011).  At this stage, I’m really beginning to feel like I have deprived my children of the secret to a healthy and happy life (as well as a few IQ points).  

However, reading on beyond the titles the evidence seems less compelling. While this is by no means an exhaustive comment on the literature, null findings were not uncommon despite alluring titles. Null effects included a link between prenatal fish oil and cognitive function in mid childhood (Campoy et al., 2011; Makrides et al., 2010); prenatal fish oil and prevention of maternal depression (Makrides et al., 2010), dietary supplements and real improvement in sports performance (Evans et al., 2012), fish oil enriched formula and intelligence (Scott et al., 1998).  

Although I am now feeling a bit better about not drip feeding my kids fresh fish or fish oil, I wondered where the evidence for the behavioural benefits of fish oil actually comes from – there surely must be some scientific evidence....  and there is. In an influential study, Hebbelm et al. (2007) document a protective relationship between higher maternal seafood intake and verbal IQ, with a detrimental effect apparent for mothers eating nil or very little seafood.  Results persisted when socio-economic factors were considered.  In a Swedish study, Kim et al. (2010) found that teenage boys who ate fish at least once a week had better school performance. I wonder though if fish consumption could be a marker of a healthy lifestyle or if findings generalise to cultures who traditionally don’t eat as much fish? Other studies have focused on clinical groups, typically ADHD and learning difficulties with these studies showing mixed results that seem to suggest some individuals respond better than others (Bloch et al., 2011; Portwood, 2006).  To date, however, research has not yet identified the factors associated with a good response.     

The literature looks a bit mixed and I am still not compelled to run out and by fish oil supplements but we all enjoyed fish for dinner last night.  Shame the kids ate theirs watching Spongebob!

For those of you going to CCN in Launceston, I hope you have a wonderful time and make the most of the opportunities for learning and networking.  Please let me know if anyone would like to post anything on the blog.

Linda and Frank

References

Bloch MH & Qawasmi A. (2011). Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis.  Journal of the American Academy of Child & Adolescent Psychiatry, 50(10), 991-1000.

Campoy C, Escolano-Margarit MV, Ramos R, Parrilla-Roure M, Csabi G, Beyer J, et al. (2011). Effects of prenatal fish-oil and 5-methyltetrahydrofolate supplementation on cognitive development of children at 6.5 y of age.  American Journal of Clinical Nutrition, 94(6 Suppl), 1880S-1888S.

Cheatham CL, Nerhammer AS, Asserhoj M, Michaelsen KF & Lauritzen L. (2011). Fish oil supplementation during lactation: effects on cognition and behavior at 7 years of age.  Lipids, 46(7), 637-45.

Escolano-Margarit MV, Ramos R, Beyer J, Csabi G, Parrilla-Roure M, Cruz F, et al. (2011). Prenatal DHA status and neurological outcome in children at age 5.5 years are positively associated.  Journal of Nutrition, 141(6), 1216-23.

Evans MW Jr, Ndetan H, Perko M, Williams R & Walker C. (2012). Dietary supplement use by children and adolescents in the United States to enhance sport performance: results of the National Health Interview Survey.  Journal of Primary Prevention, 33(1), 3-12.

Hibbeln JR, Davis JM, Steer C, Emmett P, Rogers I, Williams C, et al. (2007). Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (ALSPAC study): an observational cohort study.  Lancet, 369(9561), 578-85

Kim JL, Winkvist A, Aberg MA, Aberg N, Sundberg R, Toren K, et al. (2010). Fish consumption and school grades in Swedish adolescents: a study of the large general population.  Acta Paediatrica, 99(1), 72-7.

Kremmyda LS, Vlachava M, Noakes PS, Diaper ND, Miles EA & Calder PC. (2011). Atopy risk in infants and children in relation to early exposure to fish, oily fish, or long-chain omega-3 fatty acids: a systematic review.  Clinical Reviews in Allergy & Immunology, 41(1), 36-66.

Makrides M, Gibson RA, McPhee AJ, Yelland L, Quinlivan J, Ryan P, et al. (2010). Effect of DHA supplementation during pregnancy on maternal depression and neurodevelopment of young children: a randomized controlled trial.  JAMA, 304(15), 1675-83.

Portwood MM. (2006). The role of dietary fatty acids in children's behaviour and learning.  Nutrition & Health, 18(3), 233-47.

Richardson AJ, Burton JR, Sewell RP, Spreckelsen TF, Montgomery P (2012) Docosahexaenoic Acid for Reading, Cognition and Behavior in Children Aged 7–9 Years: A Randomized, Controlled Trial (The DOLAB Study). PLoS ONE 7(9): e43909. doi:10.1371/journal.pone.0043909

Sinn N, Cooper P & O'Dea K. (2011). Fish oil supplementation, learning and behaviour in Indigenous Australian children from a remote community school: a pilot feasibility study.  Australian & New Zealand Journal of Public Health, 35, 493-4. doi:10.1111/j.1753-6405.2011.00765.x

Scott DT, Janowsky JS, Carroll RE, Taylor JA, Auestad N & Montalto MB. (1998). Formula supplementation with long-chain polyunsaturated fatty acids: are there developmental benefits?.  Pediatrics, 102(5), E59.

Sensory-Integration Disorder...?

Apologies for the lag between posts.

It seems that the lives of working parents are busy and full to the brim.  I am personally in an adjustment phase of trying to return to work and retrieve some of my lost paediatric knowledge.  As I embark on this daunting process, I am taking the opportunity to go back to basics and try to understand some of the issues I found perplexing in the past.  One of those issues was Sensory-Integration Disorder.  From time to time, children would present with this diagnosis often accompanied by volumes of ‘supporting’ documentation.  Still I found myself trying to understand the nature of the disorder and how it could be relevant to cognitive performance.  The types of complains these children and parents would volunteer included a sensitivity to certain textures and noise.  I wondered if these sensitivities were just normal variation and if they really needed to be labelled as a disorder.  Similarly, do these complaints need treatment, which was often intensive and expensive, or would they just resolve over time?  After all, I don’t think I had ever encountered an adult complaining of sensory-integration disorder.  More perplexing though was the implication that this disorder could impact on cognition and behaviour.  I still just don’t really get the link – probably as I am still struggling to understand what is specific about this disorder rather than perhaps just being a marker of general CNS immaturity.  Recently I took my questions to Medline where “Sensory Integration Disorder” returned only two hits that in themselves were not particularly helpful.  I looked further on the internet and found the expected mix of proponents and opponents to the disorder.  I don’t necessarily feel that I have clarified my understanding of this ‘disorder’.  I suppose though that the context of the other complaints/conditions is particularly important.  Can the symptoms ascribed to ‘Sensory-Integration Disorder’ be better thought of as subsumed by other conditions, such as anxiety, ADHD or ASD? Are the symptoms real but fall short of warranting a separate disorder?  I put it over to you to further my musings over this ‘basic’ issue. 

Also for your information:

The American Academy of Clinical Neuropsychology moderates a Pediatric Special Interest Group (SIG), complete with list-server.  You do, however, need to be a member or affiliate of the AACN to access this resource.  There are some additional paediatric resources that are freely available on their website and may be worth a look.  https://sites.google.com/site/aacnped/

Abstracts close on Aug 31 for the INS meeting in Hawaii (Feb 6-9 2013). 

Linda and Frank

SpongeBob Squarepants and Executive Function Development

As a parent, I know too well how television can be a very useful and welcome aid in temporarily entertaining my child, to give me some much needed time to get things done. In fact, my fancy mobile phone has also proved to be a useful distraction and cure for a whinging baby. Given this high exposure to technology, I have often wondered whether growing up with such high tech gadgets, such as ipods, ipads, smart phones, internet and television would impact on the development of my children…

Interestingly, I recently came across an article (Lillard & Peterson, 2011) which I thought had started to scientifically explore the impact of technology on neuropsychological function and development. Reading through this article, I am surprised to find that there have been quite a few studies investigating the impact that television has on a child’s functional and neurological development. We don’t need a research program to tell us that children generally tend to watch a great deal of television, however, it seems that the literature is telling us that it watching too much television at an early age has been associated with long-term executive function and attentional problems.

The authors argue that fast-paced shows (with the ‘pace’ of shows being defined by the amount of complete scene changes within a given time frame) seem to have a particularly negative impact on attention. These events or scenes, which are presented in rapid succession, capture attention in a bottom-up fashion involving the sensory rather than the prefrontal cortices. The authors maintain that the effort to encode the rapid sequence of events could deplete children’s executive function resources, including their attentional capacity. They therefore hypothesise that watching a fast paced program will have an immediate and negative impact on a child’s executive function, compared to watching a slower paced educational program, or a self paced activity such as drawing.

Given these hypotheses, Lillard and Peterson investigated the acute or immediate impact that a fast paced popular television show, in this case SpongeBob SquarePants, has on the executive function of 4 year old children.  The viewing of SpongeBob, which is “a very popular fantastical cartoon about an animated sponge that lives under the sea”, lasted for 9 minutes, as did the viewing of a realistic cartoon about a boy, and the drawing activity. All child participants were randomly assigned to these groups. Immediately following this exposure, the children were assessed on a number of executive function tasks, assessing skills such as working memory, inhibitory control, and delayed gratification.

Interestingly, the authors found that there were no differences between the groups with regards to prior attentional problems and the amount of television watched at home (as reported by parents). Despite this, the group exposed to the fast paced SpongeBob episode performed significantly worse in executive function tasks post-exposure, than the drawing group. In addition, the difference between the face-paced and slow paced television program approached significance, with the fast-paced group again performing worse. This provides some evidence to suggest that watching a fast-paced television program can significantly impact a child’s EF processes and resources immediately following exposure. Importantly, the authors suggest that the pacing of the program may not be the only factor contributing to the depleted executive function and attentional resources. They also suggest that the “fantastical events”, or unexpected, unrealistic and novel situations and happenings within these shows may also play a major role. They argue that the encoding of fantastical events “is likely to be depleting of cognitive resources, as orienting responses are repeatedly engaged in response to novel events.”

Despite the number of limitations to this study, including a lack of a base-line executive function assessment, the assessment of 4 year olds only, the unknown and untested duration of these effects, and the limited understanding of the features of these fast paced shows that impact on executive function (fast pace, fantastical events, or something else entirely), this research raises many issues as a clinician. The first is the interesting impact that modern technology has on the neurological and functional development of children. This may result in re-assessing formulations we make, and may even prompt clinicians to start asking “how much television have you watched this morning?” before assessing each child.

As a parent, this research certainly gives me something to think about. Television may provide a temporary baby-sitter and some parental time out, although if future research acts to support these findings, maybe that short repose may not be worth the subsequent and immediate behavioural consequences.

We invite you all to read this article and comment, as we would love to hear your thoughts regarding these findings…

Frank and Linda

Reference:

Lillard, A.S. & Peterson, J. (2011). The immediate impact of different types of television on young children's executive function. Pediatrics, 128, 644-649.

Welcome to the CCN Paediatric Interest Blog

Welcome to the blog of the Paediatric Neuropsychology Interest Group of the College of Clinical Neuropsychologists!  Frank Muscara and Linda Gonzalez will be co-moderating this blog between child raising and other professional tasks.  We both have clinical and research backgrounds, so we hope the blog will be of interest to people working in a variety of paediatric positions.  Specifically we would like to use this blog to share:

• Interesting and new research findings regarding child and adolescent neuropsychological development 

• Discussions regarding the state of the art of paediatric neuropsychological assessment

• Professional Development activities relevant to our skill set 

• Any concerns and questions about the neuropsychological assessment of children and adolescents 

• Interesting and funny events that have occurred when working with young people

• Any other discussions regarding the profession in general.

Given that there may be sensitive topics discussed, we need to be aware of ethical and confidentiality issues when adding to the blog. We  are also hoping that this blog will be used as a way for clinicians to constructively and openly share information  and ideas and to support each other in their ongoing professional development.  We welcome contributions from people with all levels of experience and there is no such thing as a silly question.   So lets make this blog as supportive and as fun as possible!

If you would like to contribute regularly, please let us know, and we will put you on the list of authors of this blog. If you would like to publish only occassionally, feel free to send us your post by email, and we will upload it for you.

The blog email address is:

ccnpaediatric@gmail.com